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刘××男17岁门诊号564636 生后双上眼睑不能睁开,眼球不能转动,需仰头视物,看周围物体需转头或转身,无色盲及复视,17年来无变化。无高热及外伤史。无家族史。既往身体健康,智力正常。发育营养良好,身高1.8米,Bp120/80mmHg,心、肺、肝、脾、四肢均未见异常。视力右0.1,(+5.00D→0.2),左0.4,(+5.00D→0.6)双上睑下垂,充分睁眼时,睑裂均为3mm,压迫眉弓时,睑裂为0。双睑裂长28mm,内眦距离34mm,有内眦赘皮。眼位正,眼球固定,向水平及垂直方向转动完全受限,有轻度水平性眼球震
Liu × × male 17-year-old outpatient number 564636 After the double eyelid can not open after birth, the eye can not be rotated, the need to look up the head and look at the surrounding objects need to turn around or turn around, colorless blindness and diplopia, 17 years no change. No fever and trauma history. No family history. Past physical health, mental normal. Well-developed nutrition, height 1.8 meters, Bp120 / 80mmHg, heart, lung, liver, spleen, limbs were normal. Right eye 0.1, (+ 5.00D → 0.2), the left 0.4, (+ 5.00D → 0.6) double the ptosis, fully open eyes, palpebral fissure are 3mm, oppression eyebrows, palpebral fissure 0. Double blepharophimosis 28mm long, inner 眦 distance 34mm, with epicanthus. Eye position is positive, the eye fixed to the horizontal and vertical rotation is completely limited, with mild horizontal nystagmus